Title IV-D Child Support Application {CS500_1222}

CHILD SUPPORT CASE INFORMATION SECTION I - APPLICANT CHILD SUPPORT INFORMATION APPLICANT INFORMATION - Please complete this information about yourself Your relationship to the child(ren): Mother Father Aunt Uncle Paternal Grandparent Maternal Grandparent Guardian Other Does the child(ren) live with you? Yes If no, who does the child(ren) live with? Name: Address: City: State: Are you currently receiving Public Assistance? Did you ever receive Public Assistance? Did you ever receive Medicaid? No Zip Code: Yes Yes Yes No No No APPLICANT INFORMATION REGARDING CURRENT AND/OR PAST CHILD SUPPORT ARRANGEMENTS Please provide all available details regarding your current and/or past support arrangements. Have you ever made a private agreement with the other parent for child support? Yes If yes, Amount: $ every week two weeks month, beginning on No Are there any court actions pending in any state to establish or enforce support for your child(ren)? Yes No If yes, court (county, state): . date filed: Do you have an existing court order for child support? Yes No $ every week two weeks month starting on What court entered this order (County, State)? , The current support order requires payments to be made (check one) directly to me to a child support enforcement agency (County, State) , by income withholding directly to me by income withholding to a child support enforcement agency (County, State) , CS500 American LegalNet, Inc. www.FormsWorkFlow.com SECTION II - APPLICANT INFORMATION APPLICANT PERSONAL INFORMATION - Please complete this information about yourself Last Name: Date of Birth Social Security Number or TAX First Name: Identification Number Middle Name: Suffix: Maiden Name and/or Other Names used U.S. Citizen Yes No If No, What Country? Alien Registration No. Ethnicity: Sex: Hispanic Male Non-Hispanic Female Race: White Black American Indian, Eskimo Or Aleutian Asian or Pacific Islander Hispanic Other Primary spoken language Do you need an interpreter? Yes No If yes, specify language Home Phone Cell Phone Email Address: Drivers License number Issuing State Home Address Mailing Address if different from home address Your current Marital Status: Married Divorced Civil Union City City State State Zip Code Zip Code County Separated Widowed Never Married Single Are you married to the parent of the child(ren)? No If yes, Date: City, State of Marriage Yes Are you divorced from the parent of the child(ren)? Yes No If yes, Date: City, State of Divorce APPLICANT EMPLOYMENT INFORMATION Employer Name Self-employed (company name) Employer Address May we contact you at work? Yes No City Work Phone: Fax Number: Active Military Status Yes No Military Branch State Zip Code Work Email ID: CS500 American LegalNet, Inc. www.FormsWorkFlow.com APPLICANT ATTORNEY INFORMATION Your Attorney's Name (if you have an attorney for this case) Phone: Fax: Email: Attorney's Address City State Zip Code SECTION III - PARENT INFORMATION PARENT PERSONAL INFORMATION- Please complete this information about the parent you are filing this application against Last Name: Social Security Number or First Name: TAX Identification Number: Middle Name: Suffix: Date of Birth Place of Birth: Sex: City: Male Female State: Country Maiden Name and/or Other Names used U.S. Citizen Yes No If No, What Country? Alien Registration No. Race: White Black American Indian, Eskimo Or Aleutian Asian or Pacific Islander Hispanic Other Ethnicity: Hispanic Non-Hispanic PARENT IDENTIFYING INFORMATION: Please complete this information about the parent you are filing this application against Hair Color: Eye Color: Height: Facial Hair: Balding Black Black Brown Weight: Blond Brown Blue Green Gray/White Red Gray Hazel None/Bald unknown Other Other Distinguishing Features (Scars, Marks, Tattoos, Glasses): CS500 American LegalNet, Inc. www.FormsWorkFlow.com PARENT CONTACT INFORMATION: Please complete this information about the parent you are filing this application against Primary spoken language Home Phone Drivers License number Does the parent need an interpreter? Yes No Cell Phone Issuing State If yes, specify language Email Address: Last Known Home Address Lives with: Other Name: Parent Relative City Friend Alone State Spouse Zip Code County Last Known Mailing Address if different from home address City Is the parent currently incarcerated or institutionalized Yes No State Zip Code If yes, provide details: Name of the prison/jail/institution: City,State: PARENT'S EMPLOYER INFORMATION - Please provide information , if known, about the parent you are filing this application against Employer Name Self-employed (enter company name) Phone Number: Address Salary $ every week month Belong to Union? If Yes, Union Name Additional Employment Address Salary $ every City Type of work performed 2 weeks year Yes No Status? Active Reserve Retired Discharged 2 weeks year Yes Local # Phone Number: State Zip Code No City State Zip Code Type of work performed week month Military Service Branch: Army Navy Air Force Marines Coast Guard Duty Station: (Base/Post/Ship and City/State) (mm/yyyy) (mm/yyyy) CS500 American LegalNet, Inc. www.FormsWorkFlow.com PARENT'S HEALTH CARE INFORMATION - Please provide information, if known, about the parent you are filing this application against Health insurance provider: Child(ren) named in this application covered? Employer 1 Employer 2 Yes No Policy Number: Date coverage began: PARENT'S FINANCIAL INFORMATION - Please provide information, if known, about the parent you are filing this application against Does the parent receive any of the following types of income? Unemployment Compensation Legal Settlement Income Pension Worker's Compensation Commissions Supplemental Security Income Other disability Public Assistance (Welfare) Other Income Source Parent Bank Account Number Bank Name and Address Veteran's Administration Pension Railroad Retirement Pension Investment Income Social Security Retirement Trust Income Social Security Disability Dividend Income Royalties Rental Income Annuities Lottery Winnings Savings Checking PARENT'S ATTORNEY INFORMATION- Please provide information, if known, about the parent you are filing this application against Parent Attorney's Name Phone Attorney's Address, City, State Zip Code Fax Email CS500 American LegalNet, Inc. www.FormsWorkFlow.com SECTION IV - CHILD(REN) INFORMATION INFORMATION ABOUT THE CHILD(REN). Please provide information for each child for whom you are seeking to establish paternit